Employer / Group Information
Employer:
Delta Advanced Trucking, Inc.
Group:
Delta Advanced Trucking Benefits Plan
Policy Reference:
DAT-2025-LIFE
Employee / Insured Information
Employee Name:
Robert Johnson
Address:
1500 W Washington St, Phoenix, AZ 85003
Email:
robert.johnson@boftransport.com
Basic Life Insurance Election
Supplemental Life Insurance Election
Supplemental Life Insurance Details
Per-pay-period deduction: $2.30
Annual deduction: $59.80
Primary Beneficiary
| Beneficiary Name |
Relationship |
Address |
Allocation % |
Allocation Total |
| Demo Beneficiary A |
Spouse |
50.0 |
$50,000.00 |
| Total Allocation: |
100.0% |
$100,000.00 |
Contingent Beneficiary
| Beneficiary Name |
Relationship |
Address |
Allocation % |
Allocation Total |
| Total Allocation: |
100.0% |
$50,000.00 |
Employee Certification
I hereby certify that the beneficiary designations made are in accordance with my wishes and that I have provided all required information to the best of my knowledge.
I understand that I may change these designations at any time by submitting a written request to Human Resources.
Employee Signature
Employee Name (Print): Robert Johnson
HR/Benefits Review
HR Representative: M. Torres
Relationship Note: This form connects to benefits administration and life insurance policy management where applicable.